As Congress considers financial incentives to speed the adoption of health information technology, it must pay attention to the findings and conclusions of the study by Kaushal and colleagues (1). Their most striking observation was the estimated $48 billion annual operating costs that will be required to maintain a national health information network. These ongoing costs and the lack of financial return on investment to providers are perhaps the greatest barriers to attracting small physician practices into the information technology age. As Basch (2) correctly points out, it is this “misalignment of incentives” that translates into vast savings for payers and leaves small physician practices holding the bag.